Important Instructions:
  1. Fill this form out completely. Only "In Touch with Italy" is optional.
  2. Print out a copy for Agorà and a copy for yourself.
  3. Select the "Send enrolment form" button at the bottom of this form.
  4. Sign one copy and send it to CLA by Fax or regular post.

Enrolment Form for Minors

Student's personal information

Name
First name
 Middle name
 Last name
Address
Number
 Street
City
 Postal code
Country
Other contact information
Home phone
 Cell phone
E-mail address
Birth data
Date of birth


Gender
F M
Birthplace City

Country

Parent's or Guardian's personal information

Name

First name
 Middle name
 Last name
Address
Number
 Street
City
 Postal code
Country
Other contact information
Home phone
 Work phone
Cell phone
 E-mail address

Course information

How would you rate your knowledge of Italian? None Some Average Good Fluent

I would like to enrol my child in the following course.

Course parameters
Group course for minors for
1
2
3
4
week weeks starting on the
6th
13th
20th
27th
6th
13th
6th
July 2009.
Italia da toccare (optional) Select In Touch with Italy program number/s:
1 2a 3 4 5a 6 7a
2b 5b 7b
Accomodation Please, arrange room and full board in family for me @ 300 euros per week.
Payment I have paid an advance of euros, equal to 50% of the total course fees, by bank transfer in the name of:
Centro Linguistico Agorà
Unicredit Banca di Roma S.p.A. - Agenzia di Livorno Cogorano
Via Cogorano 3/17 - Livorno
IBAN: IT51P0300213905000002173916 - BIC SWIFT: BROMITR1DD9
Comments Please, inform us of any particular dietary, medical, or other pertinent conditions or needs, as well as other information you feel should be included.
How did you hear about Centro Linguistico Agorà?
Privacy of information I, the undersigned, do hereby Centro Linguistico Agorà to use my personal information and my child's personal information accoring to the spirit and effects of Law 675/96.
Acceptance I accept the general conditions for courses in Italian as a Second Language at Centro Lingusitico Agorà.

Parent's or Guardian's signature ____________________________________ Date ________